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Meningitis ACWY and diphtheria, tetanus and polio consent form

School Age Immunisations Team

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Consent Form: Meningococcal Group ACWY Vaccine and Tetanus, Diphtheria/Inactivated Polio Vaccine (Td/IPV)

Student First Name                  Student Surname Ethnicity Date of Birth
Home Address





Daytime Contact Telephone Number





School and Year Group GP/Doctor’s Surgery

Please COMPLETE fully and SIGN the consent box below
Must be completed by Parent or Legal Guardian only

I give consent for my child to receive the following immunisations
Meningococcal group ACWY  






       Circle  as appropriate





(Must be signed by Parent or Legal guardian)

Relationship to Student   
Tetanus, Diphtheria and Polio (Td/IPV)  






       Circle  as appropriate


Name (Print) Date

Please complete the important health questions below

  Yes (Please give details/dates) No
Does your child have any medical problems?    
Is your child taking any regular medication?    
Does your child have any severe allergies?    
Has your child ever had a reaction to previous vaccinations?    
Has your child received the Meningococcal ACWY immunisation at your GP Surgery/Travel Clinic in the last 4 years (Note: This does not include the Meningitis C only vaccine)    
Has your child received the Tetanus/Diphtheria/Polio vaccination in the last 5 years at your GP surgery or in A&E/Hospital?    

 For office use only:

Vaccine Date/Time Site of 0.5ml IM injection Batch No/Expiry Signature Print name
Meningococcal Group  ACWY


L Delt R Delt



L Delt R Delt

Thank you for completing this form, please return completed to school immediately.

All forms must be returned

Privacy statement

This service is provided by Sirona care & health, as part of the Community Children’s Health Partnership (CCHP).

Keeping your personal information safe and secure is important to us – so we’ve updated our privacy notice to reflect the changes in data protection laws.

If you have any queries about how your personal information is used or your rights, please contact our Data Protection Officer:




0300 124 5403

Data Protection Officer, Sirona care & health,  2nd Floor, Kingswood Civic Centre, High Street, Kingswood, Bristol, BS15 9TR


For office use only


IMMUNISATION CHECKLIST              YES                                                                    NO
Details correct on consent form/consent given?
Well today?
Any medical problems?
Any medication/treatment?
Any known allergies?
Any reactions to previous vaccinations?
Any possibility of pregnancy?
Checked on CHIS list?
Advice on possible side effects and their management?
Advice sheet given?


Pupil Consent: The immunisation check list has been discussed with me and I consent to this immunisation.


Pupil Signature and date:





Pupil Signature and date: